Administration of serine protease inhibitors to the stomach

ABSTRACT

The inventors have unexpectedly discovered that shock and/or potential multi-organ failure due to shock can be effectively treated by administration of liquid high-dose protease inhibitor formulations to a location upstream of where pancreatic proteases are introduced into the gastrointestinal tract. Most preferably, administration is directly to the stomach, for example, via nasogastric tube under a protocol effective to treat shock by such administration without the need of providing significant quantities of the protease inhibitor to the jejunum and/or ileum.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a 35 U.S.C. §371 U.S. National Stage Application ofInternational Application No. PCT/US2011/053019, filed Sep. 23, 2011,which claims priority to U.S. Provisional Application No. 61/385,798,filed Sep. 23, 2010, and U.S. Provisional Application No. 61/529,052,filed Aug. 30, 2011, all of which are incorporated herein by referencein their entireties.

FIELD OF THE INVENTION

The field of the invention is compositions and methods of treatingshock.

BACKGROUND OF THE INVENTION

Shock is a life-threatening complication in situations associated withtrauma including burns, surgery, ischemia, sepsis, and other criticalcare applications. Shock is a broad term that describes a group ofcirculatory syndromes, all of which result in general cellular hypoxia,and ultimately lead to irreversible cardiovascular collapse because oftheir combined effects on the microcirculation.

Shock is a multifaceted systemic response to any of a number of stressinducing stimuli that results in cellular activation and release of anumber of interacting response mediators, including cytokines,inflammatory and immune mediators, and nitric oxide (NO). During animmune response, oxygen free radicals and superoxides are generated tokill pathogens. However, oxygen free radicals and superoxides are alsodamaging to the host cells, resulting in oxidation of lipids, proteinsand nucleic acids. The mediators of shock orchestrate complex biologicalinteractions and amplification of signals that result in a systemicresponse to a localized insult.

Due to the multifaceted nature of factors inducing shock, development oftherapeutics has been difficult. Most therapies have focused on themodulation of a single factor (e.g. cytokines, NO, endotoxin) tomitigate the effects of shock. Unfortunately, inhibition of any one ofthese pleiotropic factors is ineffective. Organ specific therapies cansupport life, but are not an ideal option as they often sacrifice remoteorgan function.

One potential therapeutic molecule that has been suggested for use inshock is the bactericidal/permeability-increasing protein (BPI), aprotein involved in the immune response (Ammons, U.S. Pat. No.6,017,881). Intestinal ischemia, frequently associated with shock,results in the breakdown of the intestinal mucosal permeability barrierallowing for the translocation of bacteria and/or endotoxin from theintestinal lumen to the vascular system. During shock, endotoxin hasbeen detected in the portal vein, but its role in shock has not beenclearly defined. BPI is a protein typically isolated from granules ofmammalian polymorphonuclear cells (PMNs). PMNs are blood cells involvedin the defense of the body against invading microorganisms. BPI ishighly specific for gram negative bacteria and seems to have nodeleterious effects on other pathogens or host cells. Administration ofBPI to rats results in a decrease in the adverse physiological effectsof intestinal ischemia which may catalyze the other symptoms of shock.However BPI only affects one of the pathways that are activated inshock, so it is of limited use. Additionally, BPI acts by attacking theendotoxin and bacteria after they have been released from the intestineinto the bloodstream; therefore, it cannot be used to prevent theoccurrence of shock.

In another approach, the inventors demonstrated the role of pancreaticproteases in shock and protective effects of certain uses of proteaseinhibitors as described in U.S. Pat. No. 6,534,283. Pancreatic enzymesare released normally into the small intestine for digestion with noadverse effects. However, during shock, the intestinal permeabilitybarrier is compromised, and the inventors therefore theorized thatprotease susceptible sites not present under normal conditions arerevealed, tissues are broken down, and proteolytic products that arestrong activators of shock are released. A variety of so formedproteolytic products can act as mediators of shock, and the inventorsconsequently considered that shock is most effectively treated bypreventing in the small intestine protease activation or by theinhibition or elimination of the proteases in the small intestine thatgenerate the activators of shock. To that end, the inventors believedthat administration of protease inhibitors directly into the smallintestine would prevent shock in rats as determined by both survivaltime and molecular and histological analysis.

However, while experimental observations seemed to confirm at leastcertain effects of protease inhibitors (e.g., inhibition of theactivation of circulating neutrophils, attenuated myeloperoxidaseactivity), the inventors only considered possible prophylacticintervention using administration of protease inhibitors directly to thesmall intestine.

Thus, even though there are various methods for treatment or prophylaxisof shock known in the art, there is still a need to provide effectivemethods and compositions for treatment of shock and shock associatedconditions.

SUMMARY OF THE INVENTION

The inventors now have unexpectedly discovered that shock and/orpotential multi-organ failure due to shock can be effectively treated byadministration of liquid high-dose protease inhibitor formulations to alocation upstream of where pancreatic proteases are introduced into thegastrointestinal tract. Most preferably, administration is directly tothe stomach, for example, via nasogastric tube under a protocoleffective to treat shock by such administration without the need ofproviding significant quantities of the protease inhibitor to thejejunum and/or ileum. Thus, intervention in developing or acute shock isnow possible in a rapid, simple, and effective manner.

In one aspect of the inventive subject matter, a method of treatingshock and/or potential multi-organ failure due to shock in a mammal inwhich in one step the mammal is diagnosed as having a shock condition.In another step, a therapeutically effective amount of a proteaseinhibitor is administered (typically in a liquid formulation) at adosage of at least 20 mg/kg, wherein the liquid formulation isadministered to a location upstream of a location at which pancreaticproteases are released into the gastrointestinal tract, and wherein theliquid formulation is administered under a protocol effective to treatthe shock and potential multi-organ failure from the location. Thus, itshould be appreciated that treatment of shock can be initiated andsustained without administration of significant quantities of proteaseinhibitors to the small intestine.

Consequently, it is generally preferred that the location is the stomachand that the administration is performed via a nasogastric tube or acatheter. Alternatively, administration may also be done via an oralsolution or direct injection. While it is generally preferred thatadministration is performed using a single undivided dose per day,multiple divided doses are also deemed suitable. Moreover, it is furtherpreferred that administration is done, optionally in divided dailydoses, over at least two days, most preferably at least seven days, andmost preferably at least ten days.

In further contemplated aspects of the inventive subject matter, thedosage is at least 25 mg/kg, or at least 50 mg/kg, or at least 100mg/kg. Thus, suitable liquid formulations may include the proteaseinhibitor at a concentration of between 0.5 mM and 50 mM. Viewed fromanother perspective, administration may be performed at a daily dosageof between 2 g to 20 g.

Most typically, the protease inhibitor in the liquid formulation is aserine protease inhibitor, and/or may be tranexamic acid, FOY, ANGD,camostate, an alpha-1 anti-trypsin, a serpine, and/or an MMP proteaseinhibitor. Where desirable, a second protease inhibitor formulation maybe administered to the mammal. Such second protease inhibitorformulation may then include a protease inhibitor that is the same (ordifferent) protease inhibitor as that in the liquid formulation.Additionally, it is contemplated that an oxygen carrier may beadministered to the mammal in an amount effective to reduce organ damagedue to shock. While numerous types of shock are contemplated, especiallycontemplated shock conditions include traumatic shock, septic shock,cardiogenic shock, and hypovolemic shock. Thus, diagnosis of the shockcondition may vary considerably. However, it is generally preferred thatthe diagnosing the shock condition includes measurement of a bloodamylase and/or a blood protease activity.

In one especially preferred aspect of the inventive subject matter, themammal is a human, the protease inhibitor is FOY, and the dosage of theprotease inhibitor is at least 25 mg/kg. Most preferably, administrationwill be (once) daily administration of the liquid formulation for atleast seven days, typically performed via nasogastric tube.

Various objects, features, aspects and advantages of the inventivesubject matter will become more apparent from the following detaileddescription of preferred embodiments, along with the accompanyingdrawing figures in which like numerals represent like components.

BRIEF DESCRIPTION OF THE DRAWING

FIG. 1A is a graph depicting time course of white blood cell (WBC)count, amylase and lipase activity before and during treatment of ahuman patient according to the inventive subject matter.

FIG. 1B is an X-ray of the abdomen of the patient on day 1 showingdiffuse ileus and thickening of the intestinal wall.

FIG. 1C is an X-ray of the abdomen of the patient on day 16 showingimproved ileus.

FIG. 1D is a CT scan of the abdomen of the patient on day 1 withoutcontrast showing isodensity between pancreas (small arrow) and liver,which is inconsistent with pancreatic inflammation.

DETAILED DESCRIPTION

The inventors have unexpectedly discovered that various proteaseinhibitors may be administered in a significantly simpler manner and ata high concentration to effectively treat a developing or acute shockcondition and/or multi-organ failure due to shock. Preferably, theadministration of protease inhibitors is directly into the stomach, andmost preferably via nasogastric tube, oral solution, catheter, or directinjection at a dosage range of typically between 10-100 mg/kg. Suchadministration will not only result in rapid and simple delivery of theprotease inhibitor to the patient, but surprisingly also allows foronset and maintenance of treatment without the need to providesubstantial quantities to the small intestine.

Remarkably, adverse effects expected from the shock condition were notobserved in all subjects treated. Based on the above, the inventorstherefore expect that shock conditions can be prevented, ameliorated, orreversed using administration of protease inhibitors at very highconcentrations (significantly above 10 mg/ml) via oral administration oradministration via NG tube.

In contrast, it should be noted that U.S. Pat. No. 6,534,283, which isincorporated in its entirety by reference herein, taught administrationof certain proteases at very low dosages directly into the intestine.For example, prophylactic treatment for the prevention of shock duringcardiac surgery was contemplated to require one to eight hours prior tosurgery administration of 6-amidino-2-naphthyl p-guanidi-nobenzoatedimethanesulphonate (ANGD) orally at a dose of 0.1 to 1.0 mg/kg/hr, to afasting patient to inhibit pancreatic proteases in the intestine. Priorto surgery, ANDG was contemplated to be given by IV drip at 0.1-1.0mg/kg/hr.

Similarly, intestinal lavage for the prevention of shock duringabdominal surgery was contemplated to be performed via a catheter thatis inserted directly into the intestine, and the intestine is flushedwith a saline solution supplemented with glutathione and 0.5 to 5.0mg/kg/hr [Ethyl p-(6-guanidinohexanoyloxy) benzoate] methanesulfonate(FOY), at 1.5 to 2.5 mg/kg/hr at a flow rate of 50 to 200 ml/min for atleast 5 minutes prior to and during subsequent surgical procedures.

In yet further examples in the '283 patent, it was contemplated that intraumatic shock alpha-2 macroglobulin is administered IV and in the caseof suspected intestinal or pancreatic injury, protease inhibitors willbe administered via an esophageal tube directly into the stomach at a1-10 mg/kg initial dose for the prevention of shock. Likewise, acombination of oral prophylaxis and intestinal lavage for the preventionof shock during surgery was contemplated. Here, anti-trypsin isadministered orally preferably at a dose of 0.1 to 10 mg/kg/hr to thepatient one to eight hours before surgery. As soon as is practical afterthe administration of anesthesia, a catheter is inserted endoscopicallyinto the intestine, at the junction between the stomach and the proximalduodenum. The intestine is flushed with a saline solution supplementedwith a dose of anti-trypsin/chymotrypsin at a flow rate of 0.1 to 10mg/ml/hr, and then throughout the surgical procedure at a flow rate 0.02to 0.5 liters/min.

The inventors have now discovered that the previously contemplateddosages are under most circumstances insufficient for treatment of acuteand/or developing shock. In contrast, and especially where the rapiddelivery of the protease inhibitor is via nasogastric (NG) tube into thestomach at high dosages, rapid treatment of acute and/or developingshock is now possible.

For example, as reported in a case study from the Cheng-Hsin GeneralHospital (that was approved by Human Ethics Committee and writtenconsent by the patient), a 58-years old male heart transplant patientwas regularly followed-up in the clinic with cyclosporine,mycophenolate, and prednisolone therapy for four years. The cyclosporinelevel was kept around 150˜200 mg/dL without evidence of rejection orinfection during this period of follow-up. Before admission, the patienthad a motorcycle accident and perineum trauma. The wound wasself-managed by the patient and deteriorated after one week. He washospitalized and immediately admitted to the intensive care unit. Atpresentation, blood pressure was 80/40 mmHg in spite of aggressive fluidmanagement with 2 liters of crystalloid and colloid fluid over 5 hoursand vasopressor therapy with dopamine 5 kg/kg/min. Emergent surgicaldebridement over perineum was carried out but the clinical condition didnot improve. He was intubated and received broad-spectrum antibiotics,including teichomycin, meropenem, and caspofungin. The blood chemistryof amylase and lipase values kept raising as can be readily taken fromFIG. 1A (measurement units are: Amylase: IU/ml; Lipase: IV/ml; WBC:×10/μl), and an x-ray of the abdomen showed dilated small intestine withileus as seen in FIG. 1B. At the same time, a CT of the abdomen did notshowed edema and fluid accumulation over the pancreatic area as can beseen in FIG. 1D. The diagnosis was Fournier's gangrene complicated withseptic shock and multiple organ failure. Due to persistent septic shockand worsening septic markers, the patient received in addition adiverting colectomy and intravenous total parental nutrition.Furthermore, the patient also received a second wide debridement. Thewound culture was positive with multiple drug resistance Pseudomonasaeruginosa and Bacteroides thetaiotaomicron.

Intravenous gabexate mesilate was given for severe septic shock andelevated amylase and lipase values (as markers for presence ofpancreatic enzymes) at a dose of 3000 mg/day. At the same time, thepatient stopped all enteral feeding and total parental nutrition wasgiven with positive fluid balance of more than 1 liter per day. Butthese therapies did not reduce plasma amylase and lipase values over thenext 12 hours, and instead both values still kept rising.

Treatment was then switched to enteral gabexate mesilate infusion bycontinuous feeding into the stomach via nasogastric tube at a dose of3000 mg/day in 2000 ml of normal saline. Within a period of two days theblood pressure stabilized with minimal dose of dopamine, the glucoselevel could be controlled by reduced dose of subcutaneous insulin, andthe patient's level of conscience increased. On the third day, the doseof gabexate mesilate was reduced to 300 mg/day in a fluid volume of 2000ml and kept at this level for 10 days before discharge of the patientfrom the intensive care unit. The amylase, lipase and white blood cell(WBC) count reduced to control values (see FIG. 1A) and x-ray of theabdomen showed an improved ileus as can be taken from FIG. 1C. Threedays after enteral gabexate mesilate treatment he was extubated. On day13, the immunosuppressant medication was restored with reduced dosagecompared to the time before hospitalization and he was discharged fromthe ward after one month of admission. Five months after discharge atthe time of this report writing the patient was alive.

Thus, it should be appreciated that a developing and even acute shockcondition in a mammal (and especially human) can be treated upondiagnosis of the mammal/human with the shock condition by administrationof a therapeutically effective amount of a protease inhibitor in aliquid formulation at a dosage of at least 20 mg/kg (e.g., 400 mg in 2liter of fluid into the stomach to an average adult over a period of 24hrs), wherein the liquid formulation is administered to a location in agastrointestinal tract, wherein the location is upstream of anotherlocation at which pancreatic proteases are released into thegastrointestinal tract, and wherein the liquid formulation isadministered under a protocol effective to treat the shock and potentialmulti-organ failure from the location. While it is not excluded that atleast some of the therapeutic effect is derived from passage of theliquid formulation into and throughout the small intestine, it is notedthat the treatment according to the inventive subject matter does notrequire administration of the liquid formulation to the small intestine,which significantly facilitates treatment and increases speed.Consequently, it should be noted that the liquid formulation can beadministered directly to the stomach via nasogastric tube, catheter,direct injection, or even via a drink where the patient's conditionallows such administration.

Therefore, and viewed from a different perspective, the inventorscontemplate the use of a protease inhibitor in the manufacture of amedicament for treatment of shock and/or multi-organ failure due toshock in a mammal, wherein the protease inhibitor is formulated inliquid formulation to allow at least once daily administration to thestomach of the mammal at a dosage of at least 20 mg/kg and in an amountthat provides at least 2 g of the protease inhibitor per day.Consequently, the inventors also contemplate a protease inhibitor foruse in treating developing or acute shock and/or multi-organ failure dueto shock in a mammal, wherein the protease inhibitor is formulated in aliquid solution to allow administration to the stomach at a dosage of atleast 20 mg/kg and in an amount that provides at least 2 g of theprotease inhibitor per day.

With respect to ascertaining that a patient is developing a shockcondition and/or has acute shock, it should be noted that the shockcondition and/or organ failure may be due to a variety of causes. Forexample, especially contemplated conditions include traumatic, septic,or cardiogenic shock, shock due to surgical complications, or shock dueto complications from radiation and/or chemotherapy treatment, organperforation, chylothorax, pre-treatment for surgery (e.g., aorticreconstruction), severe bacterial infections (e.g., Fourniers gangreneand other cSSTIs, infections related to pneumonia, sepsis and/orbacteremia, community, health care associated and/or hospital acquiredinfections), and damage from mechanical ventilators, or dialysis.

Consequently, the manner of diagnosing may vary considerably, and it isgenerally contemplated that all known diagnostic manners are deemedsuitable herein and include measurement of enzymatic activity in variousbiological fluids, and especially in arterial or venous plasma,peritoneal or thoracic lavage fluid, and/or lymphatic fluid. Among othersuitable biochemical markers, especially preferred enzymatic activitiesare those from amylase, trypsin, chymotrypsin, kallikrein, elastase,MMP, lipase, and other digestive enzymes and mediators that enter thecirculatory system as a result of developing or acute shock.Alternatively, or additionally, the developing or acute shock conditionmay also be ascertained by measurement and/or identification of variousvolatile compounds as described in WO2010/087874, which is incorporatedherein.

With respect to suitable quantities of one or more protease inhibitors,the inventors observed in various animal models that shock treatmentusing protease inhibitors to block digestive enzymes requires for atleast some protease inhibitors a minimum effective dosage that issubstantially above the dosage contemplated in the '283 patent. Forexample, using tranexamic acid in rats, the minimum effective dose was100 mg/kg (127 mM in the enteral solution with 17 ml to a 350 gm rat).Here, tranexamic acid was given to rats in 18 cc of fluid. Theequivalent concentration in 2 liters (deemed suitable as human dose) is3.2 grams. The maximum dose tested in rats was 1125 mg/kg, which isequivalent to 36 grams for a human dose in 2 liters of fluid to beadministered into the lumen of the stomach or intestine. Consequently,it is generally preferred that in human, administration is performed asa single dose/day (e.g., 2 to 4 grams of Foy in 1 to 2 liter solutionwith GoLytely (PEG) or saline) over multiple days (up to 14) given viaNG tube, which has shown to be very effective.

It should therefore be appreciated that the inventors contemplateadministration of one or more protease inhibitors, and especially aserine protease inhibitor for treatment of developing or acute shock(e.g., septic, cardiogenic, traumatic) where the protease inhibitor isadministered in an aqueous pharmaceutically acceptable carrier (e.g.,saline, isotonic PEG solution, etc.) at a dosage of at least 20 mg/kg,at least 30 mg/kg, at least 40 mg/kg, at least 50 mg/kg, at least 60mg/kg, at least 70 mg/kg, at least 80 mg/kg, at least 90 mg/kg, at least100 mg/kg, and even higher. As used herein, the expression “mg/kg”refers to milligram of the protease inhibitor (or other active compound)in the administered composition per kilogram of patient body weight.Thus, the enumerated quantity is specific to the formulation asadministered, rather than to an absorbed or bioavailable quantity of theinhibitor (or other compound) in the patient. Alternatively, oradditionally, the administration of suitable protease inhibitors is alsocontemplated to be an effective prophylactic measure and administrationin such case would preferably be oral at a dosage of at least 20 mg/kg,more preferably at least 30 mg/kg, even more preferably at least 50mg/kg, and most more preferably at least 100 mg/kg. Thus, administrationmay be in a dosage range of between 20-40 mg/kg, more preferably between40-60 mg/kg, even more preferably between 60-80 mg/kg, and most morepreferably between 80-100 mg/kg. Depending on the specific type ofprotease inhibitor, the concentration will thus be preferably be between0.5 mM to 50 mM if given enteral or peritoneal. Where (additional)protease inhibitors are provided by IV, suitable dosage ranges willtypically be between 5 and 500 mg/kg. Viewed from another perspective,the total dosage of protease inhibitors administered per day willpreferably be at least 1 g, more typically at least 2 g, at least 4 g,and even as high as 10 g, as high as 20 g, and in some cases evenhigher. Pediatric total dosage will be correspondingly lower.

Depending on the severity of trauma, it is generally contemplated thathigher dosages are more preferred for conditions with more severetrauma. For example, it is contemplated that hypovolemic shock treatmentwill require higher dosages than septic shock (e.g., at least 50-100mg/kg vis-à-vis 20-50 mg/kg). It is further generally preferred that theadministration is a single administration in a volume compatible withgastric administration. For example, the total volume of liquidformulation may be equal or less than 2 liter. In alternative aspects,suitable administration volumes include equal or less than 1 liter,equal or less than 0.5 liter, and equal or less than 0.25 liter.Alternatively, higher volumes may also be used, especially whereadministration is over an extended period, or continuous.

With respect to suitable schedules of administration it should be notedthat the liquid formulations may be provided to the patient in a singledose or multiple doses per day and in some cases even continuously.Moreover, it is generally preferred that daily doses are administeredover a period of several day, most typically between 2-21 days. However,it is generally preferred that administration is continued over at least3 days, and more typically at least 7-10 days. Thus, suitable schedulesinclude administration of contemplated compounds and compositions oncedaily, twice daily, three times daily, four times daily, or even more(or continuously) over at least two days, over a period of between threeto seven days, or over a period of between 8 days to 14 days, and evenlonger (e.g., up to three weeks, four weeks, etc.). Still further, itshould be noted that in addition to direct administration to thestomach, various parenteral routes may be employed (e.g., intravenousinjection and/or intraperitoneal injection or lavage).

With respect to the protease inhibitor, it should be appreciated thatall known and pharmaceutically acceptable protease inhibitors are deemedsuitable for use herein, alone or in any reasonable combination.Especially suitable protease inhibitors include synthetic compounds suchas 6-amidino-2-naphthyl p-guanidinobenzoate dimethanesulfate (ANGD),gabexate monomethanesulfonate (FOY), diisopropylfluorophosphate (DFP),p-(Amidinophenyl)methanesulfonyl fluoride (APMSF), tranexamic acid, and4-(2-Aminoethyl) benzenesulfonyl fluoride (AEBSF), Camostate (FOY-305),and various native isolated or recombinant proteins with proteaseinhibitory activity such as serpins (e.g., SERPIN A1-A13, B1-13, C1,etc.), alpha 1-antitrypsin, alpha 2 macroglobulin, etc. Thus, and viewedfrom a different perspective, it should be noted that serine proteaseinhibitors are expressly contemplated. However, various other inhibitorsare also contemplated that have specificity for non-serine proteases,such as cysteine proteases, threonine proteases, aspartate proteases,glutamate proteases, and/or matrix metalloproteinases.

Additionally contemplated compounds with protease inhibitory activityinclude ACE inhibitors, one or more drugs that inhibits and/or rendersdigestive enzymes and/or resultant mediators inactive (which may beadministered directly into the stomach, intestine and/or anus), variousHIV protease inhibitors (e.g., saquinavir, ritonavir, indinavir,nelfinavir, amprenavir), certain diabetes drugs (e.g., Januvia,sitagliptin; vildagliptin; alogliptin; saxagliptin), one or more DPP-IVinhibitors, ulinastatin, and MMP inhibitors (synthetic and natural suchas TIMPs), and various antibiotics, including Imipenem, Merrem, Cipro,Levoquin, Trovan, Zosyn, Tygasil, Fortaz, Claforan, Rocephin, Cefotetan,Mefoxin, Unaysn, Cefobid, Ancef, Zyvox, Cubicin, vancomycin typeantibiotics etc and their generic equivalents. Therefore, it should alsobe appreciated that a second protease inhibitor may be administered,which may or may not be the same or of the same class, and which may ormay not be directly administered to the stomach.

Depending on the particular protease inhibitor, it should be appreciatedthat the carrier may vary considerably. However, it is generallypreferred that the carrier is an isotonic aqueous carrier thatpreferably contains electrolytes. Moreover, additional ingredients mayinclude glycols, and especially PEG (e.g., polyethylene glycol-3350),and pharmaceutically acceptable co-solvents. Thus, contemplatedinhibitors and other drugs may be suspended or dissolved inpolyethleneglycol or saline. For example, 0.5 to 2 liters may bedirectly administered to the stomach, and where given by IV, drippedfrom 3 to 10 hours (e.g., over 8 hours).

Furthermore, it is contemplated that additional pharmaceutically activeagents may be administered to the patient, preferably at dosages andprotocols already established. For example, suitable additionalpharmaceutically active agents include various lipase inhibitors,amylase inhibitors, albumin, and/or cytotoxic lipid binding protein, allof which may be co-administered with the protease inhibitor orseparately administered.

Moreover, the inventors have also discovered that use of an oxygencarrier (i.e., one or more chemical compounds which can carry andrelease oxygen) during treatment helped minimize the damage to theorgans. Most preferably, oxygen carriers will be those that are suitableor deemed suitable as blood substitute. Consequently, especiallysuitable oxygen carriers include various perfluorocarbon-based carriers(e.g., oxygent, oxycyte, PHER-O2, perftoran, etc.) and hemoglobin-basedcarriers (e.g., hemopure, oxyglobin, hemospan, polyheme, dextranhemoglobin, hemotech, etc.), all of which are typically formulated as aliquid prior to oxygen loading.

Administration of oxygen directly into the lumen of the intestine isthought to minimize oxygen depletion, enhance ATP production in themucosal barrier, and thereby preserve epithelial mucosal barrierfunction and enhance repair of the barrier after elevation of epithelialpermeability. Consequently, such oxygen supplementation is thought tointerfere with breakdown of the mucosal barrier in the stomach and theintestine under conditions of hypoxia and minimize escape of digestiveenzymes and consequently destruction of tissue and generation ofmulti-organ failure. Thus, it is generally contemplated to deliveroxygen via an artificial oxygen carrier into the lumen of the intestine,either as preventive measure in anticipation of hypoxia in theintestine, or to minimize tissue hypoxia as acute or chronicintervention.

Therefore, and more generally viewed, an oxygen carrier may be used fortreatment of developing or acute shock, to reduce multi-organ failureand mortality, for use in surgery in which blood flow to the intestineis intentionally or non-intentionally reduced, and for any form ofintestinal complications associated with hypoxia. Remarkably, there iscurrently no method practiced in the art to maintain oxygen at themucosal barrier during elective (e.g., surgery that requiresinterruption of blood flow to the intestine like vascularreconstructions, intestinal lesion resections, tumor resections, etc.)or non-elective clinical situations (due to trauma or disease relatedreductions of the blood flow to the intestine). And use of oxygencarriers may provide a simple solution for such problems.

For example, in a typical application during surgery or in the treatmentof developing or acute shock, an artificial blood product capable tocarry oxygen (e.g., oxygen carrier Perfluorodecalin (C10F18), CAS306-94-5, 95% mixture of cis and trans isomers) is saturated with oxygenusing well known methods and kept in an airtight container prior tosurgery or treatment. The oxygen carrier solution can then beadministered into lumen of the intestine orally, by NG tube into thestomach, or by catheter into the duodenum before or during intestinalischemia and/or shock. It should be noted that perfluorodecalin was asan ingredient in Fluosol, an artificial blood product developed by GreenCross Corporation (Japan). In typical known uses, perfluorodecalin canbe applied topically, to provide extra oxygen to a specific location, toaccelerate wound healing. Moreover, organs and tissues can be stored forlonger periods in oxygenated perfluorodecalin (e.g., the “two-layermethod” uses perfluorodecalin and University of Wisconsin solution topreserve organs before their transplantation.

The inventors have demonstrated feasibility of such approach in amammalian (rat) model with severe ischemic intestine in which enteraladministration of an oxygen carrier served to minimize intestinal damageby prevention of the entry of digestive enzymes into the wall of theintestine. More specifically, the feasibility was illustrated in a modelwith 30 min ischemia with perfluorodecalin solution (7 ml for 230 g rat)previously saturated for 10 min in oxygen. Thus, it should be noted thatgastric, duodenal, jejunal, and ileal irrigation (or otherwise exposure)may be used as a stand-alone or supplemental treatment in human andother mammals. Most typically, the volume of the oxygen carrier will beadjusted such as to allow intimate contact with the oxygen carrierthroughout the stomach, duodenum, jejunum, and/or ileum.

Most typically, administration to a human will therefore be performedvia oral administration, via gastric intubation, via catheter into thestomach and/or small intestine, etc. It should therefore be appreciatedthat the volume of the oxygen carrier per administration may varyconsiderably. However, it is generally preferred that the volumeadministered to a human is at least 100 ml, more typically at least 250ml, even more typically at least 500 ml, and most typically at least1000 ml. Administration may be performed as a single doseadministration, or in multiple doses, or even continuously, and may beperformed only once or over several days. Moreover, it should beappreciated that administration of the oxygen carrier may be performedtogether with the administration of the protease inhibitor, in analternating schedule with the administration of the protease inhibitor,or separately from the administration of the protease inhibitor.

Where co-administration with a protease inhibitor is preferred, itshould be especially appreciated that the protease inhibitor may bedissolved or dispersed in the oxygen carrier. Thus, an oxygen carriersolution is contemplated that will include a protease inhibitor at aconcentration of between 0.5 and 50 mM (or even higher). Viewed from adifferent angle, an oxygen carrier solution may be formulated to allowadministration of a protease inhibitor at a dosage of at least 20 mg/kg,at least 30 mg/kg, at least 40 mg/kg, at least 50 mg/kg, at least 60mg/kg, at least 70 mg/kg, at least 80 mg/kg, at least 90 mg/kg, at least100 mg/kg, and even higher. Thus, administration may be in a dosagerange of between 20-40 mg/kg, more preferably between 40-60 mg/kg, evenmore preferably between 60-80 mg/kg, and most more preferably between80-100 mg/kg. Viewed from another perspective, the total dosage ofprotease inhibitors in the oxygen carrier administered per day willpreferably be at least 1 g, more typically at least 2 g, at least 4 g,and even as high as 10 g, as high as 20 g, and in some cases evenhigher. Pediatric total dosage will be correspondingly lower. Likewise,mixtures of an aqueous carrier with the protease inhibitor and theoxygen carrier are also expressly contemplated herein.

It should be apparent to those skilled in the art that many moremodifications besides those already described are possible withoutdeparting from the inventive concepts herein. The inventive subjectmatter, therefore, is not to be restricted except in the spirit of theappended claims. Moreover, in interpreting both the specification andthe claims, all terms should be interpreted in the broadest possiblemanner consistent with the context. In particular, the terms “comprises”and “comprising” should be interpreted as referring to elements,components, or steps in a non-exclusive manner, indicating that thereferenced elements, components, or steps may be present, or utilized,or combined with other elements, components, or steps that are notexpressly referenced. Where the specification claims refers to at leastone of something selected from the group consisting of A, B, C . . . andN, the text should be interpreted as requiring only one element from thegroup, not A plus N, or B plus N, etc.

What is claimed is:
 1. An aqueous pharmaceutical formulation comprisinga therapeutically effective amount of 0.16 wt % to 1.80 wt % oftranexamic acid, polyethylene glycol-3350, and electrolytes; wherein theformulation has a volume of 500 ml to 1000 ml.
 2. The formulation ofclaim 1, wherein the formulation is a single dose formulation.